Experimental and Clinical Studies - JournalAgent

[Pages:9]Agri 2019;31(2):70?78 doi: 10.5505/agri.2018.10437

ORIGINAL ARTICLE

Knowledge and attitudes of nursing students about pain management

Hemirelik ?rencilerinin ari y?netimi ile ilgili bilgi ve tutumlari

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Emine KARAMAN,1 Birg?l VURAL DORU,2 Yasemin YILDIRIM1

Summary

Objectives: The purpose of the present study was to examine the knowledge and attitudes of Turkish nursing students about pain management. Methods: The participants in this cross-sectional study were 190 nursing students who were studying at a nursing faculty in western Turkey. The research data were collected between March and June of the academic year 2015?2016, using a Student Description Form and the Nurses' Knowledge and Attitudes Survey Regarding Pain (NKASRP). Results: The mean age of the students in the study sample was 23.06?1.44 years. In all, 83.7% were female, 96.8% were unmarried, 94.7% were working as a nurse, and all had social security. The mean score of the NKASRP was 15.85?3.25%. A comparison of the knowledge scores with student characteristics revealed that only the status of current employment as a nurse demonstrated a significant difference. No significant difference was detected between the NKASRP score and variables such as age and the score of the worst pain ever experienced (p>0.05). Conclusion: It was determined that the students had a generally poor level of pain knowledge. It will improve the quality of life of patients if pain management is given a greater place in undergraduate education.

Keywords: Attitude; nursing; pain; pain management; student.

?zet

Ama?: Bu ?alimanin amaci int?rn ?rencilerin ariya y?nelik bilgi d?zeylerini deerlendirmektir. Gere? ve Y?ntem: Kesitsel tipteki bu ?alima ?rneklemini T?rkiye'nin batisinda ?renim g?ren 190 hemirelik fak?ltesi ?rencisi oluturmutur. Aratirma verileri, 2015?2016 yili Mart-Haziran aylari arasinda, "?renci Tanitim Formu ve Hemirenin Ari ile lgili Bilgi ve Tutum Anketi (NKASRP)" kullanarak toplanmitir. Bulgular: ?alima ?rneklemini oluturan ?rencilerin ya ortalamasi 23.06?1.44 olup; %83.7'si kadin, %96.8'i bekar, %.5.3'? hemire olarak ?alimakta ve ?rencilerin tamaminin sosyal g?vencesi bulunmaktadir. ?rencilerin NKASRP toplam puan ortalamasi %15.85?%3.25 olarak bulunmutur. ?rencilerin bilgi puanlari karilatirildiinda, yalnizca hemire olarak g?rev yapanlarda anlamli fark olduu bulunmutur. Ya ve imdiye kadar yaanan en k?t? ari skoru gibi deikenler ile NKASRP arasinda anlamli bir fark bulunmamitir (p>0.05). Sonu?: ?rencilerin ari bilgi puanlarinin d??k olduu g?r?lm?t?r. Lisans eitiminde ari y?netimine daha fazla yer verilmesinin hastalarin yaam kalitesini y?kseltmeye yardimci olacai d??n?lmektedir.

Anahtar s?zc?kler: Tutum; hemirelik; ari; ari y?netimi; tutum; ?renci.

Introduction

Pain is an unpleasant sensation experienced by both sick and healthy people. The pain which can be experienced for various etiological reasons is among the primary symptoms of many health problems.[1] Pain has an adverse effect on a person's social life, physical, mental condition, and quality of life.[2, 3] In

addition, pain causes longer stays in hospital, and increases morbidity and mortality.[4]

Effective treatment of pain is important in raising a person's quality of life and providing comfort, for effective treatment it is essential to assess pain correctly.[2, 3] However, considering that individual

1Department of Medical Nursing, Ege University Faculty of Nursing, zmir, Turkey 2Mersin University Faculty of Nursing, Mersin, Turkey

Submitted (Bavuru tarihi) 14.12.2017 Accepted after revision (D?zeltme sonrasi kabul tarihi) 12.11.2018 Available online date (Online yayimlanma tarihi) 20.11.2018

Correspondence: Emine Karaman. Ege ?niversitesi Hemirelik Fak?ltesi, Bornova, zmir, Turkey. Phone: +90 - 232 - 388 56 20 e-mail: emine.karaman@ege.edu.tr ? 2019 Turkish Society of Algology

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Knowledge and attitudes of nursing students about pain management

characteristics can affect the perception of pain, it is difficult to assess pain objectively. Today, pain is routinely assessed as the fifth vital finding.

An important responsibility of healthcare professionals is to eliminate pain.[5] As part of the healthcare team, nurses play a major role in effective pain management. It has been stated that nurses must be sensitive to pain and have adequate knowledge of it.[6] The American Pain Society has also stated that pain is not the responsibility of the patient, but that when a patient expresses pain, pain management is the responsibility of the nurse.[7] Studies have shown that nurses' knowledge of pain, pain assessment and management is inadequate, that their knowledge generally derives from their university education.[8?14] Results of studies conducted with nursing students show similar results to studies carried out with nurses. It has been shown that student nurses'knowledge of the identification, assessment of pain and of pain control is at a medium or inadequate level.[10, 13?18]

It is clear that the knowledge of pain management of health personnel and especially of nurses evaluating pain is important in the effective management of pain. In order to strengthen the knowledge of pain of nurses as nursing trainers at this point, it is necessary to structure their degree education based on a firm foundation. By the time that students complete their university education, they should have acquired comprehensive knowledge on the topic of pain and pain management.[19] Finally, it is thought that determination of students' levels of knowledge of pain and its management can be the key to remedying deficiencies in that area. The purpose of the present study was to evaluate the level of knowledge and attitudes regarding pain management among nursing students in Turkey.

Materials and Methods

Ethical considerations The study was approved by the institutional review board (IRB) of Ege University Nursing Faculty (IRB No 2016-128). Information was given to all students concerning the objectives of the study, and their oral approval was obtained.

Study design This was a descriptive cross-sectional study.

Participant and data collection In this study, sampling was not used and the research population included all of the students. The inclusion criteria were being a student of the nursing faculty and volunteering to participate in the study. The study population consisted of 257 students, of whom 190 participated in the study, 32 did not agree to participate and 35 did not fully complete the questionnaire.

It was conducted between March and June 2016 at a nursing faculty providing degree-level education in the west of Turkey. Only intern students of the faculty were included in the study. The school of nursing grants nursing degrees after four years of education. In the first three years at this nursing faculty, time is divided equally between theory classes and practice, while in the final year integrated education is provided with emphasis on practice in the form of an internship system. At the end of their four years of education the students graduate with a bachelor's degree.

Instruments The study data were collected using a Student Description Form and the Nurses' Knowledge and Attitudes Survey Regarding Pain (NKASRP).

The student description form: This form consisted of 13 questions to specify the students' socio-demographic, educational characteristics and individual experiences of pain.

Nurses' Knowledge and Attitudes Survey Regarding Pain Scale (NKASRP): The NKASRP scale assesses nurses' knowledge and attitudes regarding pain management. There are questions on the scale about attitudes to pain management, pharmacological and non-pharmacological approaches. Of the 39 questions on the scale, 22 have true/false answers, 13 are multiple choice, and there are two questions on each of two case studies.[5, 12] Each true/false answer on the NKASRP was calculated as a percentage. Each correct answer scored 1 point, while an incorrect or unanswered question scored 0. The total score varied between 0 and 39. Correct answer rates were calculated by dividing the total number of correctly answered items by the total number of items. The NKASRP was developed by Ferrell, McGuire, and Donovan in 1993. The validity and reliability study

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of the NKASRP for Turkish society was conducted by Yildirim et al.[12] It is considered to be reliable (Cronbach's =0.74).

Statistical analysis The program SPSS 21.0 was used for the data analysis. Kolmogorov-Smirnov analysis was used to determine the conformity of the data to normal distribution. The variables were evaluated as means, percentages, frequencies and standard deviations. T test and Spearman correlation analysis were used in evaluating the data. The results were considered significant when the P-value was less than 0.05.

Results

A total of 190 Bachelor of Science nursing students completed the questionnaires. Table 1 shows data relating to the students' socio-demographic characteristics and their personal experience of pain. The mean age of the participants was 23.06?1.44 years. Most students (83.7%) were female, 96.8% were unmarried, 5.3% were working as nurses, and all had social security. It was found that 28.4% of the students smoked, and 24.7% drank alcohol.

It was found that 84.7% of the students had no health problems, and that 88.4% were not regularly using any medication. The mean score for the worst pain that they had ever experienced was 7.35?1.73, and they dealt with pain with analgesics, sleep and rest (82.6%, 47.4%, 46.3% respectively). It was found that 81.6% of the students had a relative, or a patient whose care they had been responsible for, who had experienced severe pain. Also, 73.7% of the students thought that they had an adequate level of knowledge in coping with pain (Table 1). The average correct response rate was 40.64%, ranging from 17.94% to 61.53%. Out of the 39 pain knowledge questions assessed, the mean number of correctly answered questions was 15.85?3.25 (7.0?24.0) (Table 1).

Table 2 shows the percentages of correct and wrong answers for each item on the questionnaire. It can be seen that the highest proportion of correct responses was on item 19, "After the initial recommended dose of opioid analgesic, subsequent doses are adjusted in accordance with the individual patient's response", and the lowest proportion of correct responses was on item 35, relating to narcotic and opi-

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Table 1. Socio-demographic and professional characteristics of students

Characteristic

n

%

Gender

Female

159

83.7

Male

31

16.3

Marital status

Married

6

3.2

Unmarried

The status of currently working as a nurse

Yes

10

5.3

No

180

94.7

Social security

Yes

190

100.0

No

0

0.0

Any health problem

Yes

29

15.3

No

161

84.7

Regularly use medication

Yes

22

11.6

No

168

88.4

Methods of coping with pain*

Analgesics

157

82.6

Sleep

90

47.4

Massage

53

27.9

Warm application

53

27.9

Cold application

29

15.3

Rest

88

46.3

Herbal products

13

6.8

Others

3

1.6

Smoking

54

28.4

Drink alcohol

47

24.7

The experience of pain in their relatives or patients

Yes

155

81.6

No

35

18.4

Finding adequate level of knowledge in coping with pain

Yes

140

73.7

No

50

26.3

Mean?SD (min.-max.)

Age

The score of the worst pain experienced until now

The mean scores of NKASRP

23.06?1.44 (21?36)

7.35?1.73 15.85?3.25

SD: Standart deviation; min: Minimum; max: Maximum.

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Table 2. The percentages of correctly answered items in the questionnaire

Item no

Item content (correct answer)

True or false questions

1

Observable changes in vital signs must be relied upon to verify a patient's statement

that he has severe pain. (False)

2

Because of an underdeveloped neurological system, children under 2 years of age have

decreased pain sensitivity and limited memory of painful experiences. (False)

3

If the patient can be distracted from his pain this usually means that he does NOT have

high pain intensity. (False)

4

Patients may sleep in spite of severe pain. (True)

5

Comparable stimuli in different people produce the same intensity of pain. (False)

6

Aspirin and other non-steroidal anti-inflammatory agents are NOT effective analgesics

for bone pain caused by metastases. (False)

7

Non-drug interventions (e.g., heat, music, image) are very effective for mild to

moderate pain control but are rarely helpful for more severe pain. (False)

8

Respiratory depression rarely occurs in patients who have been receiving opioids over

a period of months. (True)

9

Aspirin 650 mg PO is approximately equal in analgesic effect to meperidine (Demerol)

50mg PO. (True)

10

The World Health Organization (WHO) pain ladder suggests using single analgesic

agents rather than combining classes of drugs (e.g. combining an opioid with a non-

steroidal agent). (False)

11

The usual duration of action of meperidine (Demerol) IM is 4?5h. (False)

12

Research shows that promethazine (Phenergan) is a reliable potentiator of opioid

analgesics. (False)

13

Patients with a history of substance abuse should not be given opioids for pain

because they are at high risk for repeated addiction. (False)

14

Beyond a certain dosage of morphine increases in dosage will not increase pain relief.

(False)

15

Elderly patients cannot tolerate opioids for pain relief. (False)

16

The patient with pain should be encouraged to endure as much pain as possible before

resorting to a pain relief measure. (False)

17

Children less than 11 years cannot report pain with reliability and therefore, the nurse

should rely on the parents' assessment of the child's pain intensity. (False)

18

Based on one's religious beliefs a patient may think that pain and suffering is necessary.

(True)

19

After the initial recommended dose of opioid analgesic, subsequent doses are adjusted

in accordance with the individual patient's response. (True)

20

The patient should be advised to use non-drug techniques alone rather than

concurrently with pain medications. (False)

21

Giving patients sterile water by injection (placebo) is often a useful test to determine if

the pain is real. (False)

22

In order to be effective, heat and cold should only be applied to the painful area. (False)

Multiple choice questions

23

The recommended route of administration of opioid analgesics to patients with

prolonged cancer-related pain is: (oral)

24

The recommended route of administration of opioid analgesics to patients with brief,

severe pain of sudden onset, e.g. trauma or postoperative pain, is: (intravenous)

25

Which of the following analgesic medications is considered the drug of choice for the

treatment of prolonged moderate to severe pain for cancer patients? (morphine)

Corrrect responses

n

%

39

20.5

74

38.9

63

33.2

115

60.5

135

71.7

69

36.3

23

12.1

100

52.6

113

59.5

67

35.3

49

25.8

61

32.1

42

22.1

133

70.0

92

48.4

73

38.4

105

55.3

150

78.9

160

84.2

80

42.1

31

16.3

58

30.5

11

5.8

98

51.6

63

33.2

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PAAINRI

Table 2. The percentages of correctly answered items in the questionnaire (cont.)

Item no

Item content (correct answer)

26

Which of the following IV doses of morphine administered over a 4 h period would be

equivalent to 30 mg of oral morphine given q4 h: (morphine 10 mg IV)

27

Analgesics for post-operative pain should initially be given: (around the clock on a

fixed schedule)

28

A patient with chronic cancer pain has been receiving daily opioid analgesics for

2 months. The dose increased during this time period. Yesterday the patient was

receiving morphine 200 mg/h intravenously. Today he has been receiving 250 mg/h

intravenously for 3 h. The likelihood of the patient developing clinically significant

respiratory depression is: (less than 1%)

29

Analgesia for chronic cancer pain should be given: (around the clock on a fixed schedule)

30

The most likely explanation for why a patient with pain would request increased doses

of pain medication is: ( The patient is experiencing increased pain)

31

Which of the following drugs are useful for treatment of cancer pain? (All of the above)

32

The most accurate judge of the intensity of the patient's pain is: (the patient)

33

Which of the following describes the best approach for cultural considerations in

caring for patients in pain: (Patients should be individually assessed to determine

cultural influences on pain)

34

What do you think is the percentage of patient who over report the amount of pain

they have? Circle the correct answer. (0)

35

Narcotic/opioid addiction is defined as psychological dependence accompanied by

overwhelming concern with obtaining and using narcotics for psychic effect, not for

medical reasons. It may occur with or without the physiological changes of tolerance to

analgesia and physical dependence (withdrawal). Using this definition, how likely is it

that opioid addiction will occur as a result if treating pain with opioid analgesics? Circle

the number closest to what you consider the correct answer. (0.05).

Discussion

It is well known that the knowledge, behaviour and attitudes of the health team, especially of nurses, are important for pain control when they are performing treatment.[6, 7] The American Pain Society has emphasised the role of nurses especially in pain control.[7]

This study provides important information about the level of pain knowledge among nursing students in Turkey. The findings showed that Turkish nursing students have poor knowledge and attitudes concerning pain management. It was seen that the students in our study did not give the correct answers to basic questions on pain. These findings are consistent with past studies and the results are concerning. The literature shows us that it was seen that the knowledge levels of both nurses and nursing students regarding pain were inadequate.[8?11, 13, 15?20] Effective pain management depends on solid foundations such as physiopathological and pharmacological/nonpharmacological knowledge levels concerning pain. In spite of many changes and improvements in nurs-

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ing, pain management, reliable pain management has not yet been achieved for patients.

In a study by Yorulmaz and Aygun, most students stated that their own knowledge levels regarding pain were at a medium level, and in our study most students (73.7%) thought that their level of knowledge of coping with pain was adequate.[14] However, when students' knowledge levels were examined, it was seen that only 15.85?3.25 of the 39 questions in our study were answered correctly. Thus it was clear that students did not have the knowledge to be able to manage pain adequately. In another study performed with nursing students, it was seen that students' mean pain scores were greater than in our study.[20] We think that this difference arises from the greater number of working students in that study. This is because the mean scores of working students were statistically significantly higher than those of students who were not working.

It was found that 80.5% of the students in our study knew that patients themselves were best able to express their pain. Therefore, it was surprising to see that the students in the study did not take into account in a general sense patients' statements on pain scores in the case studies. It is thought that the reason for this is related to the students being affected by the body language of the patients indicating that they were cheerful when they were relating their pain. In the other case study in which the patient profile was similar, most students indicated the patient's pain as it had been stated, because the patient's body language was unhappy. This result also supports our view that students are affected by a patient's body language. Also, it was seen that students ignored the fact that pain is subjective and a person's responses to pain may be individual. This finding is consistent with previous findings.[16]

In pain management, the first step is to correctly determine the pain. It was seen that in this study approximately half of the students wrongly indicated the pain level in the case studies on the visual pain scale. At this point it was concluded that the step of correctly determining and assessing pain, which forms the basis of the approach to pain, had not been completely understood. These results were similar to the results of studies in the literature. In a study

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by Salatera et al. it was found that a small section of the students knew only the Visual Analog Scale from among the scales used in the assessment of pain.[17] In a study conducted with nurses it was also found that 88.1% of the nurses did not use a scale in identifying pain, and only 26% asked patients how much pain they had.[13]

Lack of knowledge in major areas regarding medications was also a concern in this research. The correct assessment of pain is as important as correct treatment. There are various pharmacological and non-pharmacological methods with regard to pain. The World Health Organization recommends ladder treatment for pain.[21] In addition, it has been found that non-pharmacological methods used in the management of pain should be integrated into treatment. In our study, it was found that the students used pharmacological treatment to alleviate pain at a rate of 82.6%, approximately half of them chose methods like sleep, rest and massage as nonpharmacological methods. Although the students chose to use analgesics as easy and practical in managing pain, it was found that their knowledge of pharmacological pain management especially of opioid analgesics was low. The most commonly incorrect items were mainly related to knowledge of pain medications and administration. This study shows that students' knowledge of the actions of analgesics, their side effects, tolerance and dependence related to the clinical use of analgesic drugs is poor. These findings were similar to those of studies in the literature.[8, 9, 11, 19?21] It is clear that the knowledge of pain, its management of both nurses and students is inadequate. Studies which have examined the pain experienced by patients support this result. In a study by the Turkish Pharmacists' Association and the Turkish Pain Association it was seen that 63% of people in Turkey suffer pain. In a situation where the knowledge levels of health personnel with regard to pain are inadequate, it is to be expected that patients will experience pain that pain will not be effectively managed. Here, education on pain comes to mind. All of the students in our study had had training on pain as part of their high school education programmes. However, it was established that there were still gaps in their knowledge of pain and pain management. In studies in the literature also, it was seen that the education of nurses on pain man-

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agement generally came from their degrees courses. [14, 22] Experts have determined that for the effective management of pain, it is necessary for the education of health team members before graduation to be continuously supported by extra training and courses.[23] The low proportion of nursing students who receive education outside the school, not holding training programmes on pain at regular intervals, not making students sufficiently aware of the importance of pain management in their degree classes may be reasons for the inadequate knowledge level.

When we examined the relationship between levels of pain knowledge in the students and socio-demographic variables, we found a significant correlation only between pain and their status as working as nurses. This suggests that nurses' in-service training can improve their pain knowledge, and in fact it was seen in other studies that nurses generally had received in-service training on pain.[13] In another study it was seen that the knowledge levels of finalyear students was lower than that of lower classes.[24] In our study, we did not carry out a comparison with lower classes, but it was determined that the pain scores of final year students were low. This may be related to not repeating education on pain given at the beginning of degree studies.

Finally, it is clear that education on pain management is important. In this study, it was determined that the knowledge levels of most nursing students on pain and its management is inadequate. However, nurses must be able to make an effective assessment of pain, to keep actual pain within "livable" boundaries by using suitable pharmacological and non-pharmacological methods. This is because pain management is known to improve the quality of life of patients. In the light of all of these findings, it is thought that the present study will provide help in determining the content of degree programmes for nursing students.

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

References

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